You can view the notes here: ESRC Seminar 6 Notes from Group Discussion
Co-production in Coercive Environments Seminar
The seminar ‘Co-production in Coercive Environments’, which took place on 6th July 2017 at the University of Huddersfield, was the sixth seminar of seven in the ERSC Seminar Series ‘Re-imagining Professionalism in Mental Health: Towards Co-production’. About 35 delegates attended, these being a mixture of researchers, academics, professionals, carers, and service users. Appropriately, the seminar took place in co-production week which was organised by The Social Care Institute of Excellence (SCIE) to celebrate the benefits of co-production and share good practice.
The seminar day consisted of an introduction by Dr Christine Rhodes of the University of Huddersfield and Dr Pamela Fisher of Leeds Beckett University. There was then a keynote talk by Professor David Pilgrim, followed by a talk from social worker and PhD student Charlotte Scott. After lunch the room was divided into smaller groups for an activity co-produced by service users, carers, staff from the University of Huddersfield, and external partners. Information and videos of the talks will be available on the web at https://coproductionblog.wordpress.com/
The appropriate definition of co-production was a topic of discussion and debate at the seminar. Roughly speaking, however, the term ‘co-production’ refers to service users and professionals working in a genuinely collaborative way in relation to some project, which might be provision of services, research, public involvement and campaigning, or any other matter of shared interest or concern.
Christine Rhodes and Pamela Fisher opened the seminar and stated that the ultimate aim when working with ‘involuntary’ service users is co-production, if this is at all possible. They pointed out that there is no single agreed definition of ‘co-production’ and indicated the risk that the term might be misused.
Pamela Fisher gave an introduction to the topic. She made an interesting connection between postcolonial theory and co-production arguing that there needs to be a ‘decolonisation’ of knowledge. She argued that service user perspectives are often not taken seriously as legitimate forms of knowledge.
She proposed that co-production is about authentic power-sharing and requires a fundamental democratising of relationships; it is connected to wider questions of citizenship and is associated with significant challenges. She ended by emphasising that it is important not only that service users should be heard, but also that their voices should carry the power to effect real changes.
Professor David Pilgrim, ‘Co-production of Mental Health Services: The Art of the Impossible?’
David Pilgrim argued persuasively that true co-production in involuntary settings is impossible. He made his case in a clear, step by step fashion. Although involuntary services could be ‘humanised’ or ‘softened’, it was his contention that this would not be ‘co-production’.
He drew attention to something that many people in secure services are affected by, but rarely speak about, namely the ‘peculiarities’ of mental health services and mental health law. Looked at afresh, he argued, it is extraordinary that people are detained, often against their will, for periods of up to six months, without trial. In any other context, he said, the State would be accused of false imprisonment and possibly assault. He also contended that the act of detaining a service user under the Mental Health Act (MHA) is less about protecting or enhancing mental health, and more about removing people exhibiting deviant or transgressive behaviour from society. He said that this may or may not be a bad thing, but called for more honesty about what was being done, to whom, and for what reason.
He set out four characteristics that in combination define co-production:
- The citizenship of non-professionals is respected and enhanced.
- Citizens and professionals are mutually dependent.
- Both parties are agreed to be rational moral agents.
- Citizens and professionals have a common agenda.
He proceeded to argue that none of these four necessary features of co-production could be achieved under the conditions of enforced psychiatric treatment. This is because:
- Enforced psychiatric detention and treatment diminish citizenship rather than enhancing it.
- Mental health professionals and service users are not mutually dependent. Service users in detention are heavily dependent on professionals, but professionals are only dependent on service users in the sense that they need jobs and salaries, and not in any wider sense.
- Service users who have been detained under the MHA are presumed not to possess rationality and moral agency.
- Professionals and mental health service users do not have a shared agenda in involuntary settings. The interests of the patients are sacrificed in the interests of those who are not patients.
David Pilgrim pointed out the interesting fact that whereas poor people under-utilise healthcare in general, this is not the case in involuntary mental healthcare where poor people are over-represented. He also touched on the inequalities present in mental health services in regard to race. He argued that mental health law should be abolished and a form of ‘dangerousness act’ should replace it.
While David Pilgrim’s position was clearly stated and well argued, I disagree with his perspective on the MHA. As a service user who has been detained under the MHA a number of times, my view is that when employed well, the MHA protects vulnerable people from danger and risk of exploitation. While I agree that MHA legislation is distinctive and ‘peculiar’, I would put forward the argument that mental distress, specifically psychosis, is itself both distinctive and ‘peculiar’, and that the legislation cannot be properly assessed without acknowledging this. I did not get much of a sense of what a ‘dangerousness act’ would entail, but I would be very worried about any dismantling of the Mental Health Act. Home treatment sounds benign, but in reality it is about a lack of funding and it can put an unbearable strain on service users and carers.
During the discussion that followed David Pilgrim’s paper, a carer made the important point that she found the talk pessimistic and passionately argued for hope for change in services. This led to a discussion about whether co-production is a product or a process. Pamela Fisher wondered whether it was something you could work towards, a journey rather than simply a destination.
Charlotte Scott, ‘Power Sharing within Coercive Environments’
Charlotte Scott is a social worker with a background in community Mental Health. She is also an Approved Mental Health Practioner (AMHP). She is in the final stages of a PhD looking at how AMHPs make decisions during MHA assessments, drawing on service users’ views of these assessments.
Like David Pilgrim, Charlotte Scott drew attention to the extraordinary and unique situation whereby the MHA could deprive someone of their liberty. She argued that detention under the MHA produces a highly coercive environment and that co-production in this setting is not achievable.
Charlotte provided a very helpful overview of a MHA assessment. While for service users this might begin with a knock at the door, for AMHPs there would have been prior behind the scenes discussion. She referred to something known as the ‘dominant narrative’. I took this to be the predominating professionally-produced account of the service user’s episode which can help build up and shape a sense of what is going on for the service user, but which can also get in the way of listening to what the service user is actually saying.
Charlotte explained that she is interested in looking at how AMHPs could empower service users, promote rights, and work in the least restrictive way, specifically during a MHA assessment. In particular she is interested in how service users’ voices can be heard. Indeed, she pointed out that the guiding principles of the Mental Health Act code of practice set out that,
“Patients should be fully involved in decisions about care, support and treatment. The views of families, carers and others where appropriate should be fully considered when taking decisions. Where decisions are taken that are contradictory to views expressed, professionals should explain the reasons for this.”
Charlotte Scott stated that these guiding principles are all very well, but she said that what matters is how they are translated into practice. In her sample (which she acknowledged may be biased because practitioners willing to be observed may be more likely to be less coercive, and to adhere more closely to the guiding principles) she found that there was a will to find the least restrictive option. She suggested that there was a “stillness to listen” and a desire to advocate for the individual person being assessed; but she noted that there was also a sense that by the point of referral for a MHA assessment other options had usually already been explored.
Although co-production in a MHA assessment was felt to be impossible, Charlotte Scott did point out some things that could help mitigate the effects of the power imbalance. These include creating an environment that is more conducive to involving the person being assessed, ensuring that the individual being assessed has time to pack, time to phone people they need to, and has money in their pocket, and also a consideration of the impact of the means of transport, for example being aware of the stigma of having an ambulance or police car on a quiet cul de sac. In addition she stressed the relevance of advance directives. These might set out what the individual would prefer to be called, what language they would like used to describe what’s going on, and jointly agreed circumstances in which intervention would be necessary.
Charlotte Scott’s talk was followed by discussion. Questions arose around how she had got ethical approval to observe MHA assessments. She explained that she had worked with a service user group from the outset to shape the study and was guided by them. Another point that arose was made by a carer who was surprised to see the guiding principles of the MHA assessment, as she had never been consulted during the MHA assessment of her sons.
The small group discussion which then took place, ‘Team Hudd’, was co-produced by service users, carers, and staff from the University of Huddersfield and external partners. At the table where I was sitting there were approximately six delegates, a facilitator and a Trust service user who also had experience of being a carer. The facilitator asked the service user questions which related to the power imbalance he had experienced in mental health services and his experience of coercion. The service user spoke about being a service user, and also being a carer to his mother who had experienced mental health problems. His mother had been given Risperidone for long periods of time without review and this had had a bad effect on her. The group discussed this situation. Each table then fed back key points to the group as a whole.
Finally, there was a discussion initiated by a delegate called Jacqui Dyer focussing on the Conservative Party’s plan to re-write the Mental Health Act. Some discussion took place, and it was suggested that Jacqui should set out her initial thoughts and the opinions of people in the room in a blog.
The seminar day was fascinating and by the end there was a real buzz of energy and excitement in the room. The talks were high quality and the general feeling was that although co-production is not possible in coercive environments, this need not stop stakeholders from aspiring and working towards it and making significant changes.
Thanks to David Pilgrim.
Also from Seminar 6, some useful visuals on influence models by Matt Ellis (South West Yorkshire Partnership NHS Foundation Trust), with thanks to Matt.
As promised, presentations from yesterday’s seminar on co-production in coercive environments.
- Introduction by Pamela Fisher & Christine Rhodes: download here
- Co-production of mental health services: the art of the impossible? by David Pilgrim (Keynote): download here
- Power Sharing Within Coercive Environments? by Charlotte Scott: download here
Thanks to the speakers for providing these materials.
University of Huddersfield 6 July 2017
We warmly invite you to participate in the 6th seminar of the series.
Encouraging debate across boundaries between service users/survivors and carers, academics, and professionals from voluntary and public organisations.
This seminar will focus on whether or not co-production is at all feasible when working with non-voluntary service users. The Mental Health Act 2007 amended the earlier 1983 Act allowing a broader range of professional staff to undertake roles associated with compulsion amongst other functions. Within England new roles have been established, including that of the Approved/Responsible Clinician, and the Approved Mental Health Clinician. The Care Quality Commission (CQC 2013) has expressed concerns that some hospitals have allowed cultures to develop where control and containment are prioritised over treatment and care.
REGISTER YOUR INTEREST HERE
To make enquiries or to apply for a travel bursary (available to service users, carers, and professionals in voluntary organisations, please email: firstname.lastname@example.org
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9.30 Registration (with tea and coffee available)
10.00 Opening with Christine Rhodes Pamela Fisher
10.15 Keynote: Professor David Pilgrim CO-PRODUCTION OF MENTAL HEALTH SERVICES: THE ART OF THE IMPOSSIBLE? This presentation begins by describing the general rationale for co-production. Applying these general considerations to mental health services, we need to take into account a range of peculiarities about mental health problems, social norms defining them and the capability of professionals to respond in a way that is accessible and acceptable. The use of coercion in services and the unusual situation of patients being detained without trial fundamentally alters the capacity of patients and staff to trust one another and work towards mutually agreed goals. Even when patients are ‘voluntary’ the risk to them of coercion, with all its threats to citizenship are constant. The prospect of true co-production in these circumstances (between professionals and patients) is constantly jeopardised. One scenario to counter these constraints is to abolish mental health law, so called. Thereafter risk management in society would bracket mental state, for example by using a form of Dangerousness Act instead. But if mental health law, so called, is retained then we can only experiment with forms of local practice, which offer a dynamic and precarious balance between State paternalism and democratic voluntarism. That balancing act will always be in the context of constraints created by services, which have developed professional norms concerned primarily with risk management. This is the art of the impossible, which will lead to some limited success but probable frequent failure.
11.15 Discussion of arising themes (with tea and coffee available)
12.00 Charlotte Scott POWER-SHARING WITHIN COERCIVE ENVIRONMENTS There is a clear tension between the value base that seeks to empower and promote the rights of individuals who receive mental health services, and the statutory powers that enable mental health practitioners to deprive an individual of their liberty in order to receive assessment or treatment for perceived mental health needs. In this presentation I will outline my understanding of the concept of coproduction in the context of statutory mental health practice, specifically during a Mental Health Act assessment when a decision is made as to whether a person will be detained against their will. I will consider how The Mental Health Act is underpinned by principles that aim to promote participation during decision making (‘The Guiding Principles’), considering how this translates to practice – drawing upon my research findings and experience when working under the Act. Discussion points will include the ways in which the views and knowledge of those who have been assessed under the Act can be given more focus in research, considering how coercion is experienced, how we define ‘power’ in this setting and how and if it is possible to shift the balance of power from those practitioners who have the power to deprive an individual of their liberty towards a shared notion of shared decision making.
1.45 Team Hudd’ Service users and carers, in co-production with the University of Huddersfield and external partners, will facilitate a round table discussion on the topic of power sharing in coercive environments. A service user will introduce the session by talking about his experiences in mental health settings. Followed by further input from service user/carer’s who will talk about their experiences with suggestions on what did and didn’t work. This will be followed by discussion at each table on the issues raised with feedback to the wider group on the key points identified.
3.00 Tea and coffee and identification of the main points arising from presentations and discussions
3.30 Additional networking opportunity
David Pilgrim PhD is Honorary Professor of Health and Social Policy at the University of Liverpool and Visiting Professor of Clinical Psychology at the University of Southampton. He trained and worked in the NHS as a clinical psychologist before completing a PhD in psychology and then a Masters in sociology. With this mixed background, his career was split then between clinical and academic work as a health policy researcher. His publications include Understanding Mental Health: A Critical Realist Exploration (Routledge, 2015) and Key Concepts in Mental Health (4th edition, Sage, 2017). Others include A Sociology of Mental Health and Illness (Open University Press, 2005- winner of the 2006 BMA Medical Book of the Year Award), Mental Health Policy in Britain (Palgrave, 2002) and Mental Health and Inequality (Palgrave, 2003) (all with Anne Rogers). His most recent book, Child Sexual Abuse: Moral Panics and States of Denial is to be published by Routledge. All of this work is approached from the position of critical realism and so the philosophy of science and social science is an overarching framework in relation to any topic.
Charlotte Scott is a Social Worker with a background in work within Community Mental Health Team’s. She is an Approved Mental Health Professional (AMHP) and has working experience of carrying out statutory work under the Mental Health Act. Currently she is in the final stages of carrying out research for a PhD, exploring how AMHPs make decisions during Mental Health Act assessments including reflections from those who are assessed under the Act on their experience of this.
Matt Ellis has worked in Social Care for over 25 years and in Mental Health as a qualified Social Worker for 15 years and Approved Mental Health Professional. He is known for his innovation and leadership pioneering creative approaches. He managed the Garage Project, a Mental Health Service for Young People that won a NIMHE (National Institute for Mental Health) positive practice award in 2005. He also chaired the local collective for Creative Minds winner of the HSJ award for ‘Compassionate Patient Care’ in 2014. More recently Matt was responsible for establishing a Recovery College in Kirklees, West Yorkshire
and has been working with the Health Information and Innovation Directorate in South West Yorkshire Partnership NHS Foundation Trust in supporting “recovery” development with 4 other colleges. Matt has now obtained the role as Principle of Calderdale and Kirklees Recovery Colleges. Matt is passionate about co-production, strengths based and creative approaches which value the contribution of those with a “lived experience”.
Donna Kemp is an academic at the University of Huddersfield. Her clinical background is as a mental health nurse, having worked in a range of settings including adult in-patient, community and crisis care. Donna was witnessed power and coercion in her professional and everyday life.
Eric Greenwood is a Lecturer/Practitioner in mental health social work at the University of Huddersfield. He is also an Approved Mental Health Professional (AMHP) in Kirklees with specialist training and responsibilities for carrying out duties under the Mental Health Act 1983 (amended 2007) and has worked in the area of mental health for over 10 years. Eric has worked in an Assertive Outreach Team which specialised in working with people with complex mental health needs, who had not engaged with mainstream mental health services.
Alison Morris is the Public Partnership Group (PPG) administrator, in the School of Human and Health Sciences at the University of Huddersfield. She is responsible for coordinating the smooth running of Service User and Carer involvement in the school. She has a back ground in youth theatre and has previously worked for various third sector organisations and charities. Alison has a son with additional needs and is a campaigner of disability rights. She also teaches healthcare professionals in hospitals and classrooms about her experiences and the communication needs required when working with both people with additional needs and their families.
Christine Rhodes is a partner of the ESRC seminar series. She works as an academic at the University of Huddersfield as the Director of Teaching and Learning in the School of human and Health Sciences. Her clinical experience is as a health care professional, as a nurse, midwife and health visitor, mainly working with people in community settings. Christine also has a lifetime of experience as a carer to a younger sibling with a complex learning disability and is very familiar with the thorny issues of power and coercion on a professional and personal level.
Hayley Roebuck is an expert by experience and has had lots of service user involvement across several departments in the School of Human and Health Sciences at the University of Huddersfield over the last twelve months. She is currently a volunteer for the music therapy service at Womencentre, having previously been a service user and volunteer for the Mothers Apart service at Womencentre. She is also an occasional volunteer for Recovery College Kirklees and Touchstone and attends the Mental Health Partnership Board and Mental Health Provider Forums in Kirklees. She believes passionately that people receiving mental health services should be “worked with” and not “delivered to” and has first-hand experience of the benefits of co-production both as a service user and as a volunteer.
Mary Rogers is a carer and a member of the University of Huddersfield Public Partnership Group. She provides insight to students and lecturers into care issues. Developing the direction of research, assessments and involvement in curriculum development in favour of Service Users and Carers. Mary has significant experience as a carer of her daughter and other family members as well as her own personal experiences and she has a wealth of expertise in working with Health Care professionals at all levels and funding authorities/ agencies.
Mary trained originally as a Pharmacist Technician and she has also worked with Doctors as a Receptionist in a busy GP practice. She has been a support assistant working with Special Needs children in a local High School before her Caring role prevailed. Mary was awarded a BA Open degree in Art Histories and Humanities mainly through the Open University, but also Huddersfield University. Mary has been a volunteer fund raiser for the local Carer’s Trust, Crossroads Care in Mid Yorkshire raising £50,000 over 3 years and became a Carer’s Trust (national) Ambassador for Yorkshire helping raise £6 million for Young Carers through the efforts of The Co-Operative Food Group she was presented to HRH the Princess Royal. She achieved The Duke of York’s Community Initiative Award on behalf of Carers Trust Mid Yorkshire from HRH the Duke of York.
Chris Thompson has lived experience of being a mental health service user and is a member of the Public Partnership group in the School of Human and Health Sciences at the University of Huddersfield and is a
member of Recovery College. He is passionate about talking openly of his experiences to combat stigma and improve understanding of mental illness. He has also started a self-help group called RECONNECT, for people who have suffered from Stress Anxiety and Depression at work. As a retired marketing director of an international company, he has professional experience of working in an environment where power and coercion are everyday occurrences. Despite being unable to attend the seminar Chris is introducing.